Treatment Must Focus on Return to Work
Under workers’ compensation insurance, mental health treatment must focus on helping occupationally injured and ill workers heal and return to work.
For detailed information, see Authorization and Reporting Requirements for Mental Health Specialists.
When treatment is covered
- Mental health conditions are caused or aggravated by a work-related injury or illness.
- A pre-existing or unrelated condition is delaying recovery from work-related injury or illness.
- When authorized — required for initial evaluation and ongoing treatment (up to 90 days at a time).
- When documentation shows clinically meaningful improvement.
Treatment that is NOT covered
- Palliative care (when treatment is not curative and rehabilitative).
- Treatment has reached maximum medical improvement.
- Temporary treatment does not improve physical function of the industrial injury or occupational disease.
Use of DSM-5 criteria is required (effective October 23, 2015)
L&I or the self-insured employer uses your information to determine the relationship between industrial injuries and mental health conditions.
During evaluation and ongoing reports, you must clearly indicate your opinion about the possible relationship between a mental health condition and an industrial injury — and the basis for your opinion using the criteria of the American Psychiatric Association’s Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
All mental health care requires prior authorization. Ongoing treatment may be approved for up to 90 days at a time.
How to request prior authorization for mental health services
|Claims insured by L&I (State Fund)||Submit Preauthorization form (F242-397-000)(downloadable)
For an initial mental health evaluation — when the diagnosis has not been established — you can leave the form’s Diagnosis Description and Causal Relationship fields blank.
|Self-insured Claims||Contact the self-insured employer or their third party representative|
Schedule for chart notes and reports
|Every visit||Chart notes||If the chart notes include all required elements listed below, then 30-day or 60-day reports are not required.|
|Every 30 days||Report||When treating and unrelated mental health condition that is retarding recovery of an accepted condition.|
|Every 60 days||Report||When treating an accepted mental health condition.|
Reporting requirements summary
Under workers’ compensation insurance, mental health treatment must focus on helping occupationally injured and ill workers heal and return to work. We require documentation that gives claim managers the information they need to make timely and fair decisions. These requirements apply to treatment for workers covered by L&I as well as by self-insured employers.
All reports must be legible, preferably electronic, and in a style that can be understood by non-medical personnel. Each report must contain at least the following:
- Diagnosis, explicitly using DSM-5 criteria and the appropriate specifier (e.g., severe vs. mild, partial remission vs. in remission),
- Relationship of the diagnosis, if any, to the industrial injury or occupational disease,
- Summary of subjective complaints,
- Objective findings,
- Time limited, intensive treatment plan focusing on functional improvement,
- Medications prescribed,
- Assessment of functional status using WHODAS 2.0 (at baseline and every 30 days),
- Assessment of targeted symptoms using standardized instruments to measure symptom severity, when indicated (e.g., PHQ-9 or BDI for depression, GAD-7 or BAI for anxiety),
- Worker’s ability to work as it relates to the mental health condition, including specific targeted symptoms that are barriers to work. Include the treatment plan related to those barriers. Recommend work modifications when appropriate.
Detailed information about how to write reports and treatment plans
- Authorization and Reporting Requirements for Mental Health Specialists
- Help in writing return to work accommodations, A to Z of Disabilities and Accommodations (from the Job Accommodation Network)
Additional documentation may be required for reimbursement. For complete information, see the Billing and Payment tab on this page.
Required - Assessment using WHODAS 2.0 (effective October 23, 2015)
- Use the 12-item WHODAS 2.0 at baseline and every 30 days to track and document the worker’s functional status.
- The 36-item WHODAS 2.0 is also acceptable. (Due to scoring differentials, the provider must consistently use the same WHODAS 2.0 instrument.)
- Score using the 0–4 method, described in the scoring templates on the WHODAS website.
- Include the WHODAS 2.0 results in required reports or comprehensive chart notes. Explain what the numerical results mean (submit a copy of the completed and scored form).
- For the initial WHODAS 2.0, indicate the domain(s) impacted by the mental health condition and how treatment will be directed to improve these areas.
- For subsequent WHODAS 2.0 results, describe the trend in the scores as they relate to the injured worker’s progress in attaining the identified goals.
For additional details on using the WHODAS 2.0 to assess workers, see Authorization and Reporting Requirements for Mental Health Specialists.
How to use the WHODAS 2.0 (on World Health Organization classifications site)
- Versions and scoring
- Online user agreement
- Available in different languages - Download the WHODAS 2.0 forms here.
Optional - Measurement of symptom severity using validated tools
|Condition||Examples of Validated Tools|
|Depression||PHQ-9 (Patient Health Questionnaire) is a 9-question self-test created as a quick assessment of mood.BDI (Beck Depression Inventory), a 21-question multiple-choice self-report inventory, is one of the most widely used psychometric tests for measuring the severity of depression.CES-D (Center for Epidemiologic Studies Depression Scale)
GAIN-SS (Global Appraisal of Individual Needs Short Screener)
|Anxiety||GAD-7 (Generalized Anxiety Disorder) is a 42-question self-assessment to help determine if symptoms are related to this disorder.BAI (Beck Anxiety Index) is a 21-question, multiple-choice, self-report inventory used for measuring the severity of anxiety.|
|Post-Traumatic Stress Disorder (PTSD)||PTSD AssessmentThe CAPS is the gold standard in PTSD assessment. The CAPS-5 is a 30-item structured interview that can be used to:
|Current or former Substance Use Disorder||CAGE-AID Cut down, Annoyed, Guilty (adapted to include drugs)AUDIT Alcohol Use Disorder Identification Test|
|Suicide Risk||Columbia suicide severity rating scale|
Billing codes and payment policies
- Fee Schedules
- Psychiatric and Psychological Services section of L&I’s 2017 Medical Aid Rules and Fee Schedules
- Mental Health Services Fee Schedule (F245-422-000)(Quick Reference Card)
Pre-authorization is key
- Use the preauthorization form (F242-397-000) to request authorization to provide services.
- When you receive your authorization, check the authorized dates of service. If they are different from what you expected, contact the Claim Manager immediately. Do not provide services beyond the authorized dates.
- Request an extension 2 weeks before the end of the currently authorized period to reduce the possibility of a disruption in care.
- Additional treatment is more likely to be authorized if your notes/reports clearly show the injured worker is improving as a result of the therapy.
Other billing information
- Find out how to bill self-insured employers and (see a list of employers)
- Use ICD-10 codes. Bill these codes the same as for all other insurers.
- Bill electronically, if at all possible. L&I offers a free electronic billing application for State Fund claims. Electronically submitted bills process faster.
- The dates of service must be within the authorized date span. Other dates will not pay.
- Use the diagnosis allowed on the claim. If you are making a new diagnosis, or adding one, use the currently allowed diagnosis on the bill, then discuss the new diagnosis with the claim manager. Note: When doing an assessment, a mental health condition may not yet be allowed. Use the diagnosis you make in the assessment.
- Use procedure codes that are current on the date of service.
- Bill for the work you do including phone calls, reviewing job analysis and return to work offers, electronic communications (via Claim & Account Center) and 60-day reports with L&I local codes (F245-422-000). Note: Some third-party billers do not bill local codes, so you may need to bill them separately.
- Monitor your submitted bills in the Claim and Account Center. Most mental health providers will need to request temporary access from the claim manager.
|Agency or Topic||Tools and Information|
|Return to Work Accommodations||Job Accommodation Network
A to Z of Disabilities and Accommodations
|Activity Coaching||An L&I treatment program to help workers increase activity and reduce psycho-social barriers to recovery.A standardized intervention delivered by professional therapists trained by the Progressive Goal Attainment Program (PGAP™).|
|Federal mental health agencies||NIMH National Institute of Mental Health SAMHSA The Substance Abuse and Mental Health Services Administration|
|Nonpharmacologic Treatments for Treatment-Resistant Depression||If conditions are met, L&I covers two non-pharmacologic neuromodulatory treatments|
|Suicide Prevention Training for Health Professionals||Department of Health’s 2017 model list of training programs
– Suicide assessment, treatment, and management training
|Suicide Prevention Hotlines||National Suicide Prevention Lifeline
800-273-TALK • 800-273-8255
|Washington Recovery Hotline||24-Hour help for substance abuse, problem gambling, and mental health (Department of Social and Health Services)
How L&I implemented DSM-5 changes
L&I has amended existing rules to implement the DSM-5 within Washington’s workers’ compensation system.
Providers must now use the criteria in the DSM-5 to diagnose mental health conditions and the WHODAS 2.0 to track and document functional status. For further details, see the WACs listed and “Authorization and Reporting Requirements for Mental Health Specialists.”
The rule changes also clarify how certain conditions may or may not be related to occupational exposure. See WAC 296-14-300 for conditions related to stress and trauma, and conditions within the Somatic Symptom and Related Disorders chapter of the DSM-5.
Laws & Rules
- WAC 296-14-300 Mental condition/mental disabilities
- WAC 296-20-330 Impairments of mental health
- WAC 296-20-340 Categories for evaluation of permanent impairments of mental health
- WAC 296-21-270 Mental health services
- RCW 51.08.142 Occupational disease – Exclusion of mental conditions caused by stress
- WAC 296-20-055 Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery.
- WAC 296-20-071 Concurrent treatment